the following questions with YES or NO. If your answer is YES, please elaborate on the details as required)

Are there past or pending cases against you?  Yes
 No
If yes, please indicate the nature, plaintiff, amount involved and the status.
Do you have past due obligations?  Yes
 No
If yes, please indicate the creditor’s name, nature, amount involved and due date.
Was your bank account ever closed because of mishandling or issuance of bouncing checks?  Yes
 No
If yes, please indicate the bank’s name, nature amount and date.
Have you ever been diagnosed, treated or given medical advice by a physician or other health care provider?  Yes
If yes, please indicate the condition/diagnosis.

 No

LOAN AND CREDIT REFERENCES
BANK/FINANCIAL INSTITUTION

ADDRESS

PURPOSE

SECURITY

HIGHEST
AMOUNT OWED

PRESENT
BALANCE

DATE
OBTAINED

DATE
FULLY PAID

TRADE REFERENCES (For Self-Employed Only)
NAME OF SUPPLIER

ADDRESS

TEL. NO.

CHARACTER REFERENCES
NAME

ADDRESS

TEL. NO.

SOURCE OF Pag-IBIG FUND HOUSING INFORMATION
 TV Ad

 Radio Ad

 Pag-IBIG Fund Personnel

 Flyer/Poster/Brochure

 Employer

 Newspaper/Magazine Ad

 Website

 Agency

 Pag-IBIG Fund Branch

 Real Estate Developer

 Seller of the Property

 Others (pls. specify) ____________

CERTIFICATION
I/We express my/our intention to purchase the Pag-IBIG Fund acquired asset as described herein and I/We further agree to purchase the property on
“as is, where is” basis.
I/We certify that the foregoing information/statement is to my/our knowledge, true, correct, complete, and updated. The signature/s appearing below
is/are genuine. I/We authorize Pag-IBIG Fund or its duly authorized representative: 1) to verify necessary information or data (i.e., certificate of employment,
pay slips and income tax return) with the concerned government agencies, any other or third parties including banks and other financial institutions from whom
Pag-IBIG Fund had obtained information; 2) to regularly submit and disclose my/our credit data (as defined under Republic Act No. 9510 and its Implementing
Rules and Regulations) to Credit Information Corporation (CIC) as well as any updates or corrections thereof; 3) to share my/our credit data with other lenders
authorized by the CIC, and credit reporting agencies duly accredited by the CIC; and 4) to send me/us updates about my/our application/account via SMS/text,
email, mail or other available means of communication.
I/We hereby further waive confidentiality rules and laws as applicable to establish correctness, validity, and authenticity of documents that would help
facilitate the processing and evaluation of my/our application.
I/We hereby agree that any misrepresentation of a material fact is a ground for disapproval of the application, cancellation of the purchase and shall be
subject to other sanctions provided in existing Pag-IBIG guidelines. I/We agree to notify Pag-IBIG Fund of any material change affecting the information
contained herein. I/We agree that all information obtained by Pag-IBIG Fund shall remain its property whether or not the application is granted.
I/We further agree to pay Pag-IBIG Fund the corresponding prescribed processing fees for the application.